Editorial Commentary: Three-Dimensional Printing and Stem Cells May Be a Game Changer for Recovery After Anterior Cruciate Ligament Reconstruction.

Placing stem cells at the tendon-bone interface of a soft tissue anterior cruciate ligament (ACL) reconstruction in an animal model accelerates graft incorporation at 12 weeks. A 3D-printed scaffold used to deliver the stem cells completely degraded at 12 weeks. Future clinical application of similar technology may improve outcomes after ACL reconstruction.

Risks, benefits, and evidence-based recommendations for improving anterior cruciate ligament outcomes.

Recently, injuries to the anterior cruciate ligament and subsequent surgical reconstructions have seen a great increase in interest from the perspectives of basic science, anatomy, mechanics, and clinical outcomes. Over the past few years, an emerging body of evidence has shown the importance of a more anatomic anterior cruciate ligament reconstruction, which uses sound anatomic and surgical principles, identifies an ideal graft for the patient, and ensures that all aspects of care (including postoperative rehabilitation) are fully addressed. It is helpful for orthopaedic surgeons to review the surgically relevant anatomy of the anterior cruciate ligament, graft choices, fixation techniques and constructs, and rehabilitation guidelines to optimize outcomes for their patients.

Medial femoral condyle strength after tunnel placement for single- and double-bundle posterior cruciate ligament reconstruction.

Single-bundle posterior cruciate ligament (PCL) reconstruction can restore normal posterior laxity; double-bundle reconstruction is needed to more closely mimic normal knee kinematics. Drilling two tunnels removes additional bone from the medial femoral condyle and may interfere with its vascular supply, increasing the risk of fracture or subchondral collapse. Three groups of seven synthetic femurs were tested: no tunnels, single anterolateral 10-mm tunnel, and double tunnel (anterolateral 10-mm tunnel and posteromedial 8-mm tunnel). The distal femur was potted to rigidly hold each specimen during testing. Compressive loading was performed at 2 mm/minute using an Instron (Instron Corp, Canton, Mass). Load and displacement at failure were recorded; stiffness was calculated from those measurements. Mean failure load of the double-tunnel group (7705 N) was significantly lower than the intact group (10962 N, P < .008). No other significant differences were detected. In this model, the double-bundle technique significantly reduced failure force, increasing the potential risk of medial femoral condyle fracture compared to the intact femur. The double-bundle technique also trended toward reduced stiffness. Therefore, a period of postoperative protected weight bearing is recommended.

Electronic medical records for the arthroscopic surgeon.

Electronic medical records (EMR) are being used increasingly in health care. Many of these have been developed for large hospitals and primary care physicians. As physicians recognize the potential benefits of increased office efficiency and improved patient care, smaller practices and specialist are beginning to evaluate EMRs. The purpose of this review is to discuss the various aspects of an EMR for the arthroscopic surgeon. Surgeons should carefully understand their specific needs and how various EMRs can meet those needs.

Factors associated with decreased muscle strength after anterior cruciate ligament reconstruction with hamstring tendon grafts.

PURPOSE: To identify factors associated with decreased muscle strength and activity after anterior cruciate ligament (ACL) reconstruction with semitendinosus-gracilis tendon (ST-G) grafts. TYPE OF STUDY: Retrospective review. METHODS: Eighty-five patients who underwent ACL reconstruction with ST-G grafts were evaluated at a mean of 44.4 months after surgery. Patients underwent isokinetic testing, physical examination, radiographs, instrumented laxity testing, and Lysholm, Cincinnati, and International Knee Documentation Committee (IKDC) ratings. Cartilage and meniscal pathology at surgery was reviewed. Strength group 1 (n = 30) showed greater than 20% deficits in strength; strength group 2 (n = 55) had less than 20% strength deficits. Activity group 1 (n = 60) maintained their IKDC activity level at final follow-up relative to preinjury level; activity group 2 (n = 25) decreased activity by 1 or more levels. RESULTS: With all patients combined, there was less than a 4% difference in mean hamstring and quadriceps strength between the reconstructed and contralateral legs at follow-up. Knee flexion deficits were associated with decreased hamstring strength. Subjective giving way and squatting/kneeling discomfort were associated with decreased quadriceps strength. Patients in strength group 1 were more likely to have squatting/kneeling discomfort and lower Cincinnati Function scores. Activity group 2 had a longer interval from injury to surgery and more chondromalacia at surgery. At follow-up, activity group 2 had lower subjective scores and was more likely to have pain, swelling, giving way, and flexion deficits. Activity group 2 also had greater deficits in quadriceps strength. CONCLUSIONS: Articular cartilage injury and meniscal pathology were not associated with decreased muscle strength. ACL reconstruction with ST-G grafts has a 38% incidence of squatting/kneeling pain that occurs secondary to patellofemoral crepitus, harvest site symptoms, and tibial hardware sensitivity. LEVEL OF EVIDENCE: Level IV, therapeutic, case series, no control group.

Arthroscopic capsular plication-shift.

We describe a technique of arthroscopic capsular plication and shift used to address both anterior and posterior capsular laxity. This technique is used when the labrum is intact or if laxity persists after labral repair.

Anterior capsulorrhaphy: an in vitro comparison of volume reduction--arthroscopic plication versus open capsular shift.

PURPOSE: The purpose of this study was to objectively compare volume reduction after arthroscopic plication and open lateral capsular shift. TYPE OF STUDY: Experimental cadaver study. METHODS: Fifteen fresh-frozen human cadaver shoulders were assigned to 1 of 2 groups: arthroscopic plication (n = 7) or open lateral capsular shift (n = 8). Initial capsular volume was measured by repeated injection of a viscous fatty acid sulfate solution and recorded for each specimen. Repeated measurements were taken after the procedure to determine volume reduction. RESULTS: Both procedures resulted in reduction of capsular volume. The arthroscopic plication resulted in a 22.8% volume reduction and the open lateral capsular shift resulted in a 49.9% volume reduction. Comparison of the 2 procedures revealed significant volume reduction after open lateral capsular shift compared with arthroscopic plication (P = .00001). Repeated measurements confirmed that the injection technique was valid and reproducible. CONCLUSIONS: The lateral capsular shift resulted in significantly greater volume reduction compared with arthroscopic plication. Based on these results, we recommend an open lateral-based capsular shift for patients with multidirectional instability in which a larger capsular shift is required. However, additional plication sutures may allow for an even further reduction in volume. The amount of volume reduction required to eliminate instability still remains unknown for patients with shoulder instability caused by capsular laxity. LEVEL OF EVIDENCE: Level IV Case Series, in vitro anatomic comparison of 2 surgical procedures.

In vitro analysis of rotator cuff repairs: a comparison of arthroscopically inserted tacks or anchors with open transosseous repairs.

PURPOSE: The purpose of this study was to employ a cyclic loading protocol to compare rotator cuff repair strengths of arthroscopically inserted cuff tacks and suture anchors with the traditional open transosseous suture repair. TYPE OF STUDY: In vitro cadaveric analysis. METHODS: Full-thickness 1 x 3-cm rotator cuff defects were created in 25 fresh-frozen cadaveric shoulders, and were randomized to 1 of 4 repair groups: (1) open repair with transosseous sutures, (2) arthroscopic repair with 2 singly loaded suture anchors, (3) arthroscopic repair with 2 doubly loaded suture anchors, and (4) arthroscopic repair with cuff tacks. All repairs were cyclically loaded from 10 to 180 N, and the numbers of cycles to 50% (5-mm gap) and 100% (10-mm gap) failure were recorded. RESULTS: The number of cycles to 100% failure was significantly higher for the arthroscopic doubly loaded suture anchor repairs when compared with the (1) open transosseous suture repair (P = .009), (2) arthroscopic cuff tack repair (P = .003), and (3) arthroscopic singly loaded suture anchor repair (P = .02). Additionally, the number of cycles to 50% failure was significantly higher for all anchors versus open or tack repair (P = .03 for both). CONCLUSIONS: Immediate postoperative fixation of rotator cuff repairs with doubly loaded suture anchors was more stable than that provided by the open transosseous suture repairs, arthroscopic singly loaded suture anchors, or cuff tacks. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process. CLINICAL RELEVANCE: These in vitro results indicate that superior immediate postoperative fixation of rotator cuff repairs may be achieved with the doubly loaded suture anchors. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process.

The Tuckahoe knot: a secure locking slip knot.

We describe a simple and easy-to-tie knot that can slide and lock. The benefit of these characteristics is that when the knot is seated and locked, it is secure in that it will not slip before the 3 reversed half-hitches with alternating posts are placed.

Arthroscopic management of calcific tendinitis of the popliteus tendon.

Calcific tendinitis is seen most commonly affecting the rotator cuff but has not been previously reported affecting the popliteus tendon. Symptoms mimic a tear of the posterior horn of the lateral meniscus. Arthroscopic debridement of the calcific deposit results in resolution of symptoms.

Chronic lateral knee instability treated with a high tibial osteotomy.

Published studies have recommended correction of osseous alignment in patients with chronic deficiencies of multiple knee ligaments and varus angulation. However, similar treatment for isolated chronic lateral collateral ligament deficiency has not been reported. We report such a case treated successfully with a medial high tibial osteotomy using a dynamic external fixator.

Computer-assisted and robotic surgery in orthopedics: where we are in 2014.

Successful outcomes after orthopedic surgical procedures are believed to be highly dependent on reproducible anatomic accuracy. Immediate intraoperative feedback helps surgeons to achieve this accuracy as has been demonstrated with the use of fluoroscopy. Non-image-based computer navigation has been used in joint arthroplasty, anterior cruciate ligament reconstruction, high tibial osteotomy, and cartilage procedures along with applications in hip and shoulder arthroscopy. Most short-term studies have demonstrated superior accuracy when compared with conventional techniques; however, very few studies have shown better clinical outcomes. Robotic-assisted surgery has been most popular in total and unicompartmental arthroplasty, which again has greater accuracy but similar clinical outcomes when compared with conventional techniques. Economic analyses indicate that these high-cost technologies may only be cost-effective in high-volume centers. Other studies have shown that computer navigation improves the accuracy of lower volume surgeons to a greater degree than higher volume surgeons allowing the former to have results similar to the latter.

All-inside arthroscopic meniscal repair with meniscal cinch.

The number of commercially available all-arthroscopic meniscal repair devices has increased in recent years. Although inside-out vertical mattress sutures have been considered the gold standard in the past, recent biomechanical studies have shown that some all-arthroscopic repair devices provide comparable strength. To successfully use these devices, surgeons must understand proper insertion technique. The purpose of this article is to demonstrate this technique for the Meniscal Cinch (Arthrex, Naples, FL).

A biomechanical study of stability of the elbow to valgus stress before and after reconstruction of the medial collateral ligament.

The purpose of this study was to assess the stability of the elbow to valgus loads after reconstruction of the anterior bundle of the medial collateral ligament (MCL). The MCL in 14 human cadaveric elbows was exposed with a muscle-splitting approach. Each sample was secured in a materials test frame,5 N-m valgus moments were applied in 30 degrees, 60 degrees, 90 degrees, and 120 degrees of flexion, and baseline stability was measured. This sequence was performed after the anterior bundle was sectioned and again after ligamentous reconstruction was done with the Jobe technique. At 30 degrees, 60 degrees, 90 degrees, and 120 degrees of flexion, reconstruction reproduced an average of 99%, 102%, 97%, and 89%, respectively, of the stability of the intact ligament. The only significant difference between intact and reconstructed samples was at 120 degrees of flexion (P <.05). We concluded that this procedure reliably restores stability to a ruptured MCL throughout the flexion arc in the immediate postoperative period.